Pinocchio shows how to end the tobacco epidemic

Department of Medicine and Center for Tobacco Control Research and Education, University of California, San Francisco, California

Correspondence to Stanton A Glantz, Professor of Medicine, Center for Tobacco Control Research and Education, University of California, Box
1390, Room 366 University Library, San Francisco, CA 94143-1390, USA; glantz{at}medicine.ucsf.edu

When Tobacco Control published its first issue in 1992, the idea of ending the tobacco epidemic was not even on the horizon. Indeed, the goal
was merely to get control of the problem.

Now, 20 years later, serious people are discussing ending tobacco as a public health problem. Finland and New Zealand have officially established the goal of doing so by 2040 and
2025, respectively. While specific efforts are just beginning to take shape, even establishing such a goal would have seemed
silly even a few years ago.

One important reason that it now makes sense is that we have proven technologies to cut tobacco use that have been successfully
enacted and implemented by policy makers.1 Smoke-free environments, strong anti-tobacco media (especially when it confronts the tobacco industry directly) and substantial
tax increases all undermine the social acceptability of tobacco use and reinforce the tobacco-free norm in rich countries
and in countries with emerging economies.2

There is a new broad appreciation that smoking in the movies is a major key media channel promoting tobacco use worldwide
for both youth34 and young adults.5–9 (The tobacco companies have known this since the 1920s and spent decades quietly using film to promote smoking.1011) In the USA, smoking in movies accounts for 44% of youth initiation.12 The relative importance of onscreen smoking is likely to be more important in countries with greater restrictions on conventional
tobacco marketing.1314 There is a dose–response for the effect of smoking in movies on smoking behaviour.34 This consensus has led to a broad effort4 to reduce onscreen smoking by integrating tobacco into film rating systems to give an adult content rating for tobacco use
in films. Because producers are unlikely to accept a less profitable adult rating just to keep smoking in a film they hope
to market to youth, there will be an economic incentive to leave tobacco out of films designed to be marketed to youth, substantially
reducing the level of exposure and consequent effects on youth initiation. There has already been substantial progress in
reducing the amount of smoking onscreen.15

In addition to direct regulation, policies could create market incentives that would lead the tobacco companies themselves
to change their marketing techniques. For example, governments could impose fees on the companies based on the amount of their
products consumed by children each year.16 The companies, of course, loudly claim that they do not want kids to smoke (or chew or snus) while profiting for decades
by creating new addicts. Setting this fee at the discounted present value of all future consumption of their products by these
new young consumers would remove the economic benefit to the companies of addicting children. Setting the fee at an increasing
multiplier over time would create an active economic disincentive for recruiting new young smokers and other tobacco users.
In order to maximise profits, the companies would then have to implement increasingly aggressive steps to avoid attracting
youth to their products.

Policy makers can be shown that, contrary to conventional wisdom, aggressive general market tobacco control programmes (not
ones focused on youth) have rapid positive impacts on healthcare costs because of rapid reductions in heart disease and, a
bit later, cancer. The California tobacco control programme started impacting health costs after just one year, an effect
that grew to 7% of health costs after 15 years.17 Similar, albeit smaller, results were observed in Arizona, which has a less aggressive programme.18 As non-communicable diseases and healthcare cost containment move to centre stage globally, eliminating tobacco use becomes
the obvious first and biggest step to make progress.1920

Another important development has been the broad acceptance of the tobacco industry as a vector that spreads disease and corrupts
the policymaking process.21 The understanding that it is important to insulate the policymaking process from the tobacco industry led directly to WHO
Framework Convention on Tobacco Control Article 5.3 that seeks to insulate policy making from industry influence.22 It has also led public health advocates around the world to urge other organisations and politicians to refuse the industry's
money and ‘partnerships.’23–28

All these steps have reduced the industry's legitimacy, which both undermines their political power and creates an environment
in which consumers do not want to affiliate with the tobacco companies by buying their products.252930

Of course, none of this will be easy. The companies are always on the lookout to buy or seduce friends and political protection
or to promote new ‘reduced harm’ products31 and ‘responsible regulation.’32 We need to avoid such seductions and keep in mind the fact that the tobacco companies always follow the strategies that they
think will maximise profits in the long run.

But, the end is in sight.

In early 2011, a friend showed her 2½-year-old granddaughter Walt Disney's 1940 Pinocchio, a cartoon filled with smoking.

The little girl did not know what the characters were doing. She had to have it explained.

World Health Organization. WHO Framework Convention on Tobacco Control (2008) Guidelines for Implementation of Article 5.3: Guidelines on the Protection
of Public Health Policies with Respect to Tobacco Control from Commercial and Other Vested Interests 2008, 2008. http://www.who.int/fctc/guidelines/article_5_3/en/.